Sandwell Health and Wellbeing Board Tuesday 12th January, 2017 at 4.30pm in Committee Room 1 at the Sandwell Council House, Freeth Street, Oldbury

Agenda (Open to Public and Press) 1.

Apologies for Absence

2.

Declarations of Interest in matters to be discussed

3.

To confirm the Minutes of the meeting held on 22nd November, 2016 Main Discussion Item

4.

Priority 3 – We will work together to join up services – proposed board development plan (spring board to priorities)

Paul Southon

For discussion/decision 5.

Adult mental health joint strategic needs and assets assessment (Paul Southon)

Paul Southon

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0 – 4 years joint strategic needs assessment

Jyoti Atri

For Information [IL0: UNCLASSIFIED]

7.

Chairs correspondence – Police and Crime Commissioner. (police and health and wellbeing boards)

8.

Board forward plan (standing item)

Paul Southon

Dates of future Meetings at 4.30pm on: Thursday 2 March 2017  Thursday 4 May 2017

Jan Britton Chief Executive Sandwell Council House Freeth Street Oldbury West Midlands

Distribution: Voting Members of the Board: Sandwell MBC Representatives: Leader of the Council – Cllr S Eling; Cabinet Member for Social Care – Cllr A Shackleton; Cabinet Member for Children’s Services - Cllr S Hackett; Cabinet Member for Public Health and Protection – Cllr P Gill. Sandwell and West Birmingham Clinical Commissioning Group: Vice-Chair - Chair of Sandwell Health Alliance locality/CCG Partnership lead - Dr Basil Andreou; Chair of Black Country Commissioning locality - Dr Ian Sykes; Healthworks Locality – Dr Ram Sugavanam. Healthwatch Sandwell Chair of Healthwatch Sandwell – John Clothier

[IL0: UNCLASSIFIED]

Non-Voting Members of the Board: Sandwell MBC: Director - Adult Social Care, Health and Wellbeing - David Stevens; Director of Children’s Services - Matthew Sampson; Director - Public Health - Jyoti Atri. NHS England - Birmingham, Solihull and the Black Country Area Team Director of Operations and Delivery – Vacant. Sandwell and West Birmingham Clinical Commissioning Group: Accountable Officer - Andy Williams.

Discretionary Members:West Midlands Police Chief Superintendent Matthew Ward. West Midlands Fire Service:Group Commander Steven Ball Sandwell Voluntary Sector Organisation:Chief Executive Mark Davies Sandwell and West Birmingham Hospitals NHS Trust Chief Executive Toby Lewis. Black Country Partnership NHS Foundation Trust Deputy Chief Executive - Tracy Cotterill

Agenda prepared by Shane Parkes Democratic Services Unit - Tel: 0121 569 3190 Email: [email protected]

This document is available in large print on request to the above telephone number. The document is also available electronically on the Committee Management Information System which can be accessed from the Council’s web site on www.sandwell.gov.uk Please note that this meeting may be filmed by members of the public and press, and may be filmed by the Council for live or subsequent broadcast on the Council’s website. [IL0: UNCLASSIFIED]

[IL0: UNCLASSIFIED]

Agenda Item 1

Apologies

To receive any apologies from members

Agenda Item 2

Declarations of Interest

Members to declare any interests in matters to be discussed at the meeting.

Minutes of the Sandwell Health and Wellbeing Board 22nd November 2016 at 4.30pm at Sandwell Council House, Oldbury Present: Sandwell Metropolitan Borough Council (SMBC): Councillor Ann Shackleton (Chair) Cabinet Member for Social Care; Councillor Simon Hackett Cabinet Member for Children’s Services; Councillor Syeda Khatun Deputy Leader – Cabinet Member for Neighbourhoods and Communities; Councillor Preet Gill Cabinet Member- Public Health and Protection; Jyoti Atri Director - Public Health. Sandwell and West Birmingham Clinical Commissioning Group (CCG): Andy Williams Accountable Officer, CCG. Healthwatch Sandwell: John Clothier

Chief Exec. Healthwatch Sandwell.

West Midlands Police: Matthew Ward

Chief Superintendent WMP

West Midlands Fire Service: Neil Griffiths Group Commander WMFS Steven Ball Group Commander WMFS Sandwell and West Birmingham Hospitals NHS Trust: Toby Lewis Chief Executive of Sandwell and West Birmingham Hospitals NHS Trust; Sandwell Voluntary Sector Organisation Mark Davis Chief Executive. Apologies: Councillor Steve Eling Dr Basil Andreou

Leader of Sandwell Council; (Vice Chair) Chair of Sandwell Health 1

[IL0: UNCLASSIFIED]

Sandwell Health and Wellbeing Board – 22nd November, 2016

Dr Ram Sugavanam Dr Ian Sykes Christine Guest David Stevens Matthew Sampson Tracey Cotterill In attendance: Paul Southon Dawn Maycock Conrad Parke Diane Osbourne Rosalind Baker

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Alliance, Locality/CCG Partnership Lead; Healthworks Locality; Chair of Black Country Commissioning Locality; Divisional Manager Adult Social Care SMBC; Director - Adult Social Care, Health and Wellbeing; Director – Childrens Services Deputy Chief Executive.

Health and Wellbeing Programme Manager SMBC; Health and Wellbeing Board Project Officer SMBC; RGF Programme Manager SWB CCG Commissioning Manager. Mental Health Project Officer – Changing our Lives

Minutes The minutes of the meeting held on 1st September, 2016 were confirmed as a correct record. The Chair asked that best wishes for a speedy recovery be sent to Doctor Andreou who had recently undergone surgery. Main Discussion Items

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Priority 2 update – Prevention of Violence and Exploitation. The board received a presentation and watched a film entitled ‘Craig’s Story’, a case study of a young violent convicted offender from a neighbouring borough. The Health and Wellbeing Board had agreed that the prevention of violence and exploitation was the theme for the board’s priority 2; “we will help people stay safe and support communities”. This was a shared priority across all four statutory partnership boards.  Health and Wellbeing Board;  Sandwell Safeguarding Children’s Board; [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016  

Sandwell Safeguarding Adults Board; Safer Sandwell Partnership Police and Crime Board;

At the meeting on 1 September 2016 (minute no. 51/16), the board agreed the next steps for delivery of priority 2. There had been progress made against each of the agreed next steps. This included the preparation of a draft action plan that operated across all four statutory partnership boards. As part of the needs assessment, service mapping was underway across the council, police, NHS and wider partners. Board members were asked to circulate the service mapping template to the relevant officers in their organisations. For the action plan to progress, the health and wellbeing board would need to review the plan. This included a decision on whether the proposed role for the board in the action plan was correct or whether the plan needed amending. The proposed governance for the programme was through the Joint Partnership Board, which included the chairs of all four boards. A small partnership task and finish group currently managed delivery of the priority. As the work programme developed there may be a need for dedicated capacity to programme manage delivery across the four boards and wider partners. A personnel specification would be prepared to outline the skills required for the support role. Partners would consider if they had capacity within their organisations to support this role. The Chair commented that it would be necessary to focus on deliverables and outcomes. This would be brought back to the board in the future. For discussion/decision 59/16

Mental Health and Wellbeing Standards feedback from launch event At the Health and Wellbeing Board on the 12th May, 2016 (minute no. 27/16, the Sandwell Mental Health Parliament presented the quality of life standards. [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016

The board received feedback from the event which was held on the 18th October 2016, to launch the standards. Norman Lamb MP endorsed the standards with an impassioned speech about the importance of people who had life experience of mental health having choice and independence in their care. The event was well attended, with representation from councils, NHS commissioners, NHS providers, voluntary and community based organisations and people with lived experience of mental health services. The quality of life standards were being included in service commissioning by Sandwell and West Birmingham Clinical Commissioning Group. An Ideas Festival was a tool for working in coproduction with people with lived experience of mental health problems and the community. An ideas festival had been arranged for the 27 th January 2017, and the board was invited to attend. It was planned to develop a community place of safety café. This would be community based and self-sustaining it was felt that this would relieve pressure on Accident and Emergency departments. Changing our Lives were exploring ways of securing investment from large businesses and grants. The Chair asked if there would be an age limit on the place of safety. It was confirmed that there would not be an age limit, however, as this was an evening initiative it was unsuitable for young children but could be used by Adolescents. The board would be updated on progress at a future meeting. 60/16

Child and Adolescent Mental Health Services (CAMHS) transformation plan update The Board received a progress report on the refreshed CAMHS Local Transformation Plan. The original plan had been submitted in October 2015 and had been fully approved with an 88% assurance rating from NHS England. The transformation plan outlined clear plans for a five [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016 year term. The plan had been approved by the governing body and presented to the Health and Wellbeing Board at the meeting on the 3rd March 2016, (Minute Number 21/16). NHS England requested the refresh in October 2016, the draft was submitted on the 7th October and following assurance from NHS England the plans were approved and published by 31 st October. Feedback from NHS England on the draft refresh gave Sandwell and West Birmingham CCG an assurance rating of ‘Fully Confident’ with just four minor issues to address. The Key priorities were as follows: To develop a single point of access;  To explore links to adults emotional wellbeing and mental health services;  To develop a crisis management and home treatment service;  To develop an Eating Disorder service;  To Improve Access to Psychological Therapies programme, and improve early intervention provision;  To provide a 136 suite (place of safety);  To complete a training needs analysis, and commission multiagency training on emotional wellbeing and mental health concerns;  To improve the IT systems and CAMHS physical environment;  To improve neurodevelopmental provision for Autism Spectrum Disorder and Attention deficit hyperactivity disorder. The successes to date were outlined. The single point of access was a multi-agency venture with a clear directive and a monitoring process. Data and information gathered from the evaluation in May 2016 was being used to inform on future improvements with regard to the procurement of the new Emotional Health and Wellbeing model and incorporated the management of the point of access. The establishment of a community based primary mental health worker service had been commissioned in line with Government policy. The focus of the service had been switched to one of early intervention and prevention. The service provided nine workers in Sandwell in various locations. [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016

A place of safety suite had been established for vulnerable children and young people at Penn Hospital, Wolverhampton. The provider trust had liaised with all relevant emergency services to make them aware of the service which would prevent vulnerable young people being placed into police custody. The home treatment and crisis intervention team continue to progress and the team operates seven days a week from 8am – 8pm, a 24/7 provision would be available by 2020. There had been problems with recruitment however both elements were in place in Sandwell. Sandwell had joined the East Midlands Learning Collaborative and the children and young people Improve Access to Physiological Therapies (IAPT) was integral to the whole system of Children and Young People’s Mental Health Transformation. The workforce in Sandwell would be improved through training. The board’s view had been that the engagement service must be a strong voice for children and young people, championing their rights and reducing the impact of inequalities. The tender process was completed in November and Brook had been awarded the contract. Links had been made to Adult Mental Health as follows:  Gold standard Early Intervention to Psychosis service, 8am – 8pm aged 14-35;  Access to the Triage: rapid support for vulnerable children and young people;  Development of an all age Eating Disorder Service. A CAMHS practitioner had been appointed into the early year’s team, the post commenced in July 2016 and improvement had been made by increasing the capacity within the team. The priorities for 2017–18 were detailed in the plan, NHS England had made an offer of additional funding. A business case was being prepared for an initiative to reduce waiting times. A further offer of additional funding had been received from NHS England two weeks ago. CAMHS and the youth justice team are [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016 developing a health worker post to work with the youth offending team and young people in custody. Further updates on progress would be brought to the Health and Wellbeing Board in the future and the link to the final CAMHS transformation Plan circulated to the Board. 61/16

Board development session – 27th September, 2016 (update/feedback) The Health and Wellbeing Programme Manager updated on the development session. The board recognised that there had been substantial restructuring across board partners and there was a need to understand how the board had been affected and how it needed to change to remain effective. Based on the findings from the workshop, three themes for board development had been proposed. i. Developing partnerships, relationships and trust between board partners; ii. Making sure the board was able to deliver on their priorities; iii. Making the board more accessible and an effective forum for partnership decision making and for making a positive difference for the people of Sandwell; The Executive group would develop a draft action plan based on the three areas to bring back to the board in January.

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Update on Midland Metropolitan Hospital The board received a report from the Partnership and Regeneration Manager regarding the Midland Metropolitan Hospital and the planned development of the surrounding Smethwick and Ladywood area and the impact on those communities. The Hospital would be open in October 2018 and up to six new housing development sites consisting of approximately 6,500 new homes had been planned. The Planning and Public Health teams from Sandwell MBC and Birmingham City Council would like to propose an approach that views these new assets as not only health and housing investments but an investment that could positively impact across a whole range of issues and across a whole community in terms of indicators such as employment, educational [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016 attainment, healthy lifestyles and social cohesion. An Urban innovation Action Award of £3 million over the next three years had been made. There would be an impact assessment of the regeneration work associated with the hospital development. The approach to this is being agreed, it would identify the potential health benefits and harms from the initiative and how the benefits can be maximised and the harms minimised. If a proactive approach were adopted to maximise the impact of these assets it would help deliver a successful, sustainable hospital at the heart of a neighbourhood that offered better quality of life for the community with happier, more prosperous people benefiting from better education and better employment prospects with minimal extra funding required. It was important to create a safe and secure environment for those living and working in the area. A cross departmental and inter-agency approach to asset based regeneration could then be used on many other assets, existing and new across other neighbourhoods in Birmingham and Sandwell. A number of the workforce who would be based in the hospital already resided in the area. A cross border Stakeholder event had been planned for March 2017 to obtain senior support and commitment to the regeneration plans. 63/16

Update on Sustainability and Transformation Plan The Accountable Office for the CCG updated on the Sustainability and Transformation plan. Black Country and West Birmingham had published their proposals to transform local services on the 21st November 2016, along with an executive summary. 18 local health and social care organisation had contributed to the development of the proposals. The key commitments were: The Midland Metropolitan Hospital;  New Models of Care;  Primary care;  Maternal and Infant Health - reducing mortality. [IL0: UNCLASSIFIED]

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Sandwell Health and Wellbeing Board – 22nd November, 2016

Local people were invited to have their say on the proposals through a comprehensive programme of engagement, beginning with a public event on 6th December at Bethel Convention Centre, Kelvin Way, West Bromwich, B70 7JW. The Cabinet Member-Public Health and Protection remarked that it was necessary to integrate health and social care and a public voice was essential to getting it right. For Information and/or Comments 64/16

Board forward plan – standing item The updated plan had been circulated to members. Date of Next Meeting the next meeting of the Board would be held at 4.30pm on Thursday 12th January, 2017.

(Meeting ended at 6.20pm)

Contact Officer: Shane Parkes Democratic Services Unit 0121 569 3190

[IL0: UNCLASSIFIED]

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Agenda Item 4

Sandwell Health and Wellbeing Board Date 12 January 2017 Report Topic: Contact Officer:

Priority 3: We will work together to join up services – proposed board development plan Health and Wellbeing Programme Manager

Purpose of Report:  To propose a plan for the future development of the board  To seek the views of board partners and gain board agreement to the plan Key Discussion  The board held a development workshop, points: facilitated by the Local Government Organisation, on 27 September 2016  Following discussion at the board on 22 November 2016 the board executive group was asked to prepare a draft board development plan based on three themes; o Developing partnerships, relationships and trust between board partners o Making sure the board is able to deliver on its priorities o Making the board more accessible and an effective forum for partnership decision making and for making a positive difference for the people of Sandwell  The executive group has developed the draft development plan for discussion at the board. This plan is attached to this report.  The proposal is that, when the board has agreed the final development plan, the board executive group will monitor delivery of the plan. Recommendations  That the board discusses the proposed plan and comments on changes needed to the plan  That the board agrees to the Health and Wellbeing Board executive group monitoring delivery of the plan

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Implications (if applicable) Financial No financial implications Wider Engagement Other

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Sandwell Health and Wellbeing Board (DRAFT) Board Development Action Plan Objective Action 1. Developing partnerships, relationships and trust between board partners Support board members to understand - The next board development workshop to each other’s roles, priorities and include ‘getting to know each other’ sessions challenges for board members - Discuss with the Local Government Association to see what support is available to facilitate board development

Delivered by

When

HWB executive

Proposal to March HWB

Support new board members to understand the governance and priorities of the board

- Develop a formal induction for new board members, including meeting with other board members and health and wellbeing board executive

HWB support officers

April 2017

Ensure clarity of governance and decision making pathways for the board and for each of the board members

- Develop and agree a clear description of the decision-making pathways for all partners, including the role of the HWB within these pathways

HWB executive / HWB board

May 2017

Board to nominate board member lead.

May HWB meeting

2. Making sure the board delivers its priorities Clear governance and oversight of each of the board priorities

Each board priority to have a named board member lead and identified lead officer - Board lead responsible for maintaining an overview of the delivery and progress for the 13

priority and reporting this to the board on a Board member lead to nominate quarterly basis - Lead officer to be responsible for coordinating lead officer. and monitoring delivery of a priority action plan - All priorities to provide update reports to the board quarterly - Detailed reports and board discussions twice yearly for each priority, with exception reporting when needed to ensure continued progress in delivering the priority Ensure a focus on the board priorities

All board reports to describe how they contribute to delivery of one or more of the board priorities - How they will deliver clear outcomes and positive change for the people of Sandwell - Guidance to be prepared for report authors - Reports to be reviewed for compliance

Board support officers / HWB executive

March HWB meeting

Ensuring actions from board discussions are captured and followed up

3 questions to be asked at the end of every item discussed at the board - Does this item need to come back to the board? - If yes, when does it need to come back? - What does the board expect when it comes back? - All returning items to be scheduled into the board forward plan

Board support officers

Immediate

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Work of the HWB to be co-ordinated - Boards to share the priorities and delivery with the other statutory partnership plans with the other boards boards - HWB Priority 2 (prevention of violence and - Health and Wellbeing Board exploitation) is a shared priority across all four - Safer Sandwell Partnership and boards Police and Crime Board - Joint Chair’s group to have oversight of - Sandwell Safeguarding Children’s delivery plans to ensure the work of the Board boards is coordinated where appropriate - Sandwell Safeguarding Adults Board 3. Making the board accessible and an effective forum for partnership decision making Tell people what the board is doing, allow people to comment, ask questions and influence delivery of the board priorities

- Work with existing engagement groups and networks to raise awareness of the board priorities and to develop routes for consultation with stakeholders o E.g. SHAPE, older people’s ambassadors, mental health and learning disability people’s parliaments, voluntary and community sector - Produce and share clear and concise descriptions of the current board priorities and action plans - Develop routes for people to ask questions or comment on plans - Produce clear descriptions of what is discussed and decided in board meetings, to be shared through existing networks 15

Democratic services and board support officers Chairs of the partnership boards

HWB executive

Plan to the March HWB

Review what would help people become more involved in the work of the board

HWB support - Consult with local people about what they want to know about the work of the board and officers what would make the board more accessible. Potential approaches; o Using community and partner venues for board meetings o Streaming board meetings online o Producing plain English records of meetings

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May 2017

Agenda Item 5

Sandwell Health and Wellbeing Board Date 12 January 2017 Report Topic: Contact Officer:

Adult Mental Health Joint Strategic Needs and Assets Assessment Health and Wellbeing Programme Manager

Purpose of Report:  To update the board on progress on the preparation of the joint strategic needs and assets assessment (JSNAA)  To summarise the findings from the needs assessment  To set out the plan and timescale for completion of the JSNAA Key Discussion  The board agreed that the scope for the first points: phase of the adult mental health JSNAA would focus on access into services and on access to recovery and support for independent living  The JSNAA has been developed through a coassessment approach. This has included consultation and involvement from a range of statutory and voluntary sector partners and people with lived experience of mental health services.  Information and data were gathered from commissioners and providers of mental health services, from service users and people with lived experience. Information was also provided by nonmental health providers who support vulnerable people and people with mental health problems.  The needs assessment describes what is known about the levels of wellbeing, common mental health disorders and severe and enduring mental illness in Sandwell. The indications are that the levels of mental illness in Sandwell are higher than the national average, though not all data sources are consistent.

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 The range of services available in Sandwell have been mapped, including operating hours and waiting times where this information is available.  Key findings so far have identified deficits and assets related to wellbeing and mental health services in Sandwell. The main themes are;  Substantial challenges in emergency crisis referral pathways and access to assessment and treatment  Unclear pathways into assessment and treatment for routine referrals, including inconsistency in people being discharged for non-attendance and needing re-referral.  Difficulties for people with substance misuse problems accessing mainstream services for support.  A lack of overall coordination of pathways, referral routes, and access to assessment and treatment across all partners  The contribution provided by non-mental health providers and organisations in supporting people with mental health problems. These are an important asset that provide much support to vulnerable people and their contribution is not always fully recognised.  There needs to be more coordination of approaches, pathways and support between statutory and voluntary mental health providers and the non-mental health providers that are supporting vulnerable people and people with mental health problems.  A need for a coordinated approach to workforce development across all partners, including increased training and support for non-mental health providers.

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 Further analysis is needed of the information gathered from partners and people with lived experience.  Once this analysis is complete, work will be undertaken with all partners to develop and agree the final recommendations from the JSNAA.  The final JSNAA, with recommendations, will be prepared ready for the next board meeting on March 3rd 2017.  The role of the partnership mental health strategy group has recently been reviewed. This group will provide the partnership forum that will develop and deliver a partnership mental health transformation plan for Sandwell, based on the recommendations from the JSNAA. Recommendations

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That the board discusses and comments on the JSNAA and the findings presented.  That the board receives the final JSNAA at the next board meeting in March 2017.

Implications (if applicable) Financial No financial implications Wider Engagement A wide range of partners and stakeholders have been involved in developing the JSNAA. Other

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Sandwell Joint Strategic Needs Assessment

Adult Mental Health and Well-being in Sandwell A Needs and Assets Assessment

Item 6a Draft Adult MHW Jsnaa 04/01/2017 21

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Contents Executive Summary.................................................................................................................... 4 Recommendations ..................................................................................................................... 5 Adult Emotional Health and Wellbeing in Sandwell: A Needs and Assets Assessment ............ 6 1. Introduction .................................................................................................................... 6 Objectives for the Joint Strategic Needs and Assets Assessment ..................................... 6 Asset Based Approach ....................................................................................................... 6 Definitions of emotional health and well-being ................................................................ 7 2. The determinants of mental health and wellbeing ........................................................ 8 3. Wellbeing, mental health and mental illness in Sandwell ............................................ 17 Wellbeing in Sandwell ...................................................................................................... 17 Common mental health conditions: ................................................................................ 19 Referrals into services ...................................................................................................... 23 Suicide and self-harm....................................................................................................... 26 Severe and enduring mental illness ................................................................................. 27 Perinatal Mental Health ................................................................................................... 28 Co-existing mental illness and substance misuse ............................................................ 28 Health of people with mental illness ............................................................................... 30 Vulnerable groups ............................................................................................................ 31 4. Policy and Guidance ...................................................................................................... 34 National policy ................................................................................................................. 34 Local Policy ....................................................................................................................... 38 5. Evidence: National Institute of Health and Clinical Excellence .................................... 40 6. Service Mapping Exercise ............................................................................................. 49 Mental health providers commissioned by Sandwell and West Birmingham Clinical Commissioning Group ...................................................................................................... 49 Mental health providers commissioned by Sandwell Metropolitan Borough Council ... 51 Access to Mental Health Providers .................................................................................. 52 Referral Pathways ............................................................................................................ 53 Waiting Lists ..................................................................................................................... 54 Exclusion Criteria.............................................................................................................. 55 Non Mental Health Providers .......................................................................................... 56 Non mental health providers: referral pathways ............................................................ 59 Suggested improvements to mental health provider services ........................................ 60 What could make things better? ..................................................................................... 62 Workforce development .................................................................................................. 63 Item 6a Draft Adult MHW Jsnaa 04/01/2017 22

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Feel good 6 Wellbeing Activity in Sandwell ..................................................................... 63 Stakeholder event feedback ............................................................................................ 64 Acknowledgements.............................................................................................................. 66 References ........................................................................................................................... 67

List of Figures Figure 1: Sandwell population estimates by sex (25+) .............................................................. 9 Figure 2: Population by ethnicity (25+) ................................................................................... 10 Figure 3: Risk and protective factors in Sandwell .................................................................... 16 Figure 4: Wellbeing in Sandwell, responses to the ONS 4 wellbeing questions ..................... 18 Figure 5: Referrals by ethnicity 2011/12 to 2015/16 .............................................................. 21 Figure 6: Referrals by ethnicity: Ethnicity compared to population proportion: total referrals 2011 to 2015 ............................................................................................................................ 22 Figure 7: Referrals by age: Total referrals 2011 to 2016 ......................................................... 24 Figure 8: Referrals by gender 2011/12 to 2015/16 ................................................................. 25 Figure 9: Referrals by source of referral .................................................................................. 25 Figure 10: hospital stays for self-harm, Sandwell and England: 2012/13 to 2014/15 ............ 26 Figure 11: Age-standardised mortality rate from suicide and injury of undetermined intent per 100,000 population: Sandwell, West Midlands and England ........................................... 27 Figure 12: Levels of mental health and wellbeing problems in services ................................. 57

List of Tables Table 1: Common mental health conditions: summary indicators ......................................... 20 Table 2: Hospital contacts for common mental health disorders ........................................... 22 Table 3: Prescribing levels of medications for common mental health disorders .................. 23 Table 4: Severe and enduring mental illness: summary indicators ......................................... 27 Table 5: Estimates of women with mental health problems during pregnancy and after childbirth .................................................................................................................................. 28 Table 6: Co-existing mental illness and substance misuse: summary indicators .................... 29 Table 7: Health of people with severe mental illness in Sandwell: summary indicators ........ 30 Table 8: Mental health providers commissioned by the Clinical Commissioning Group ........ 49 Table 9: Mental health providers commissioned by SMBC ..................................................... 51 Table 10: Service operating hours ........................................................................................... 52 Table 11: Referral pathways and routes .................................................................................. 53 Table 12: Waiting lists .............................................................................................................. 54 Table 13: How well providers feel they meet the needs of service users ............................... 58 Table 14: Effectiveness of referral pathways........................................................................... 59 Table 15: Access to mental health services: positive and negative stakeholder responses ... 62

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Executive Summary To be completed for final JSNAA following final analysis of responses.

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Recommendations To be developed and agreed with partners, providers and people with lived experience.

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Adult Emotional Health and Wellbeing in Sandwell: A Needs and Assets Assessment 1. Introduction Objectives for the Joint Strategic Needs and Assets Assessment The purpose of this Joint Strategic Needs and Assets Assessment (JSNAA) chapter is to support the people of Sandwell, and the commissioners and providers of services, in maintaining and improving mental health and wellbeing in Sandwell. The JSNAA will,     

Identify the assets that exist within the communities of Sandwell to support people’s mental health and wellbeing Identify the levels of need in relation to mental health and wellbeing Provide an overview of the relevant evidence and guidance Describe how these needs are currently addressed and identify gaps in provision Make recommendations for action

This will help with;    

Recognising, supporting and building on the existing assets within the communities of Sandwell Developing joint approaches to support people with maintaining and improving their emotional wellbeing and mental health Commissioning interventions that will improve emotional health and well-being and support early intervention Commissioning services for people experiencing both common and severe and enduring mental health problems

Asset Based Approach The Department of Health, in Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategies Explained, describes joint strategic needs assessments as “The means by which local leaders work together to understand and agree the needs of all local people 1”. However, understanding the needs alone can lead to a deficit-based approach. This can fail to recognise the value of the assets that already exist within communities. These include community leaders and activists, community and voluntary sector organisations and the knowledge, skills and experience that exist within communities. In producing this needs and assets assessment, the intention was to capture the assets as well as the needs in Sandwell. To do this we used a co-design approach. Co-design is a stage within co-production, which is defined as;2 “Delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours.” Item 6a Draft Adult MHW Jsnaa 04/01/2017 26

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Local people with lived experience (including the Sandwell Mental Health Parliament), voluntary sector organisations and statutory commissioner and provider organisations have been involved throughout the writing of the JSNAA.

Definitions of emotional health and well-being There are a number of different terminologies used to describe emotional wellbeing and mental health. For the purposes of this needs assessment the definitions used are taken from Better Mental Health for All, published by the Faculty of Public Health in 2016 3. Public mental health Public mental health is a term that has been coined to underline the need to emphasise the neglected element of mental health in public health practice. It spans promotion, prevention, effective treatment, care and recovery. It is built on the same principles as all areas of public health. Mental health The term mental health describes a spectrum from mental health problems, conditions, illnesses and disorders through to mental wellbeing or positive mental health. This emphasises positive health rather than illness, and is informed by the widely recognised WHO definition of mental health, ’... a state of wellbeing in which the individual realises his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community’. Wellbeing We use the term wellbeing as synonymous with the 1946 WHO definition of health – a state of mental, physical and social wellbeing. This is a holistic state to which all aspects of the human being contribute. The term wellbeing is often used as synonymous with mental wellbeing partly, perhaps, to counterbalance prevailing trends to focus on physical wellbeing. Mental and social wellbeing are inextricably linked in both cause and effect ways. Indeed the definition of mental wellbeing includes the capacity for healthy relationships. Mental wellbeing The term mental wellbeing is used in this report to cover the positive end of mental health covering both the hedonic (feeling good) and eudemonic components (functioning well). Feeling good is subjective and embraces happiness, life satisfaction and other positive affective states. Functioning well embraces the components of psychological wellbeing (selfacceptance, personal growth, positive relations with others, autonomy, purpose in life and environmental mastery). Resilience The term resilience is used to mean ‘being able to cope with the normal stress of life’ and ‘bounce back from problems’. This is an important component of many definitions of mental wellbeing, with great relevance for the prevention of mental health problems. Mental health problems Item 6a Draft Adult MHW Jsnaa 04/01/2017 27

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We use the term mental health problems synonymously with poor mental health or to cover the range of negative mental health states including, mental disorder – those mental health problems meeting the criteria for psychiatric diagnosis, and mental health problems that fall short of diagnostic criteria threshold. Mental health problems can be further categorised into the common mental problems such as anxiety and depression which may be transient (relapsing, remitting and recovered); and severe mental health problems such as schizophrenia and bipolar disorder; and the various behavioural disorders. Person with lived experience/experts by experience There has been a move within the field of mental health, largely led by people with lived experience, to avoid the term ‘patient’ and use instead alternatives including ‘survivor, ‘service user’ and person with lived experience/experts by experience. This language draws on the social model of disability, which moves away from defining people by a clinical diagnosis or service use to focus on people’s individual and collective everyday realities. Seventy five per cent of people with a mental health problem of a severity to warrant diagnosis, do not receive secondary mental health services, and thus may never regard themselves as a ‘patient’ or ‘service user’.

2. The determinants of mental health and wellbeing This section will provide a brief overview of the determinants of mental health and wellbeing and, where possible, descriptions of how these determinants affect the people of Sandwell. Within the narrative, there are references that provide more detailed information and discussion. Unless otherwise indicated, the data used is from the Public Health Outcomes Framework website4. The social, economic and physical environments in which people live have a strong influence on their mental health and wellbeing; these are the social determinants of health. The World Health Organisation report “Social Determinants of Mental Health” provides a detailed examination of this topic5. The independent Foresight Mental Capital and Wellbeing Project Final Report states that; An individual’s mental capital and mental wellbeing crucially affect their path through life. Moreover, they are vitally important for the healthy functioning of families, communities and society. Together, they fundamentally affect behaviour, social cohesion, social inclusion, and our prosperity.6 At all stages of life, the risk factors for common mental health disorders are strongly associated with poverty and disadvantage. The relationship with wellbeing is less clear, wellbeing is more strongly associated with education and the quality of social relationships. The British Social Attitudes Survey 2016 explores people’s attitudes towards mental health and wellbeing7. People said that spending time with family, work-life balance, having enough sleep and finances were the most important influences on their mental wellbeing.

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These findings from the survey align with the New Economics Foundation five ways to wellbeing8. Individual Factors Gender is a factor in the risk of common mental disorders such as depression, with women having a higher prevalence, incidence and morbidity associated with depressive disorders compared with men. It is thought that these differences are due to a combination of biological, psychological and sociocultural vulnerabilities9. The population of Sandwell over the age of 25 has a higher proportion of females than males, in line with the national population10.

Figure 1: Sandwell population estimates by sex (25+)

Source: NOMIS Population estimates - local authority based by single year of age https://www.nomisweb.co.uk/query/construct/summary.asp?mode=construct&version=0&dataset=2002

The risk of depression is disproportionately higher in people from the African-Caribbean, Asian, refugee and asylum seeker communities11. The Ethnic profile in Sandwell differs to the national average, with a higher proportion of ethnic minorities:

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Figure 2: Population by ethnicity (25+)

Source: Nomis - % derived from ONS 2011 Census data - Ethnic group by sex by age

As illustrated above, Sandwell has a higher proportion of people aged 25 and above from the Black and Minority Ethnic (BME) community (25.5%) compared to both the West Midlands (13.5%) and England (11.8%)10. 

The 2011 census showed that in the Sandwell 25+ age group there were: o 34,841 people of ‘Asian/Asian British’ ethnicity o 11459 people of ‘Black/African/Caribbean/Black British’ ethnicity o 2966 people of ‘Mixed/multiple ethnic group’ ethnicity o 2935 people of ‘Other ethnic group’ ethnicity

Education, Learning and Development A higher level of educational attainment is a protective factor for mental health5. Inversely, low educational attainment is linked to a higher risk of common mental health conditions (anxiety and depression)12. Access to educational opportunities is important in promoting mental health, resilience and wellbeing, and lifelong learning reduces the risk of mental illness6,13. Learning is thought to improve overall wellbeing and recovery from mental health problems by improving self-esteem, self-efficacy, sense of purpose and social integration8. 



Sandwell has a relatively poor level of educational attainment, with only 48.9% of pupils achieving 5 or more A*-C GCSEs (compared to England average of 57.3% and West Midlands average of 55.0%). 22.2% of Sandwell residents have no qualifications (compared to England average of 8.6% and the West Midlands average of 13.0%)10.

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Childhood While children and adolescents are outside the scope of this document, childhood mental health and wellbeing is important to consider in relation to adulthood. The Children and Young People’s Emotional Health and Wellbeing in Sandwell (2016) JSNA report provides more detail on this area. The evidence is clear that the social determinants of health such as housing, education, employment and environment, are major influences on children and young people’s emotional health and wellbeing. Poor mental health and wellbeing in childhood is negatively associated with many adult health outcomes, including poor adult mental health, higher rates of alcohol and substance misuse and an increased risk of suicide14.   27.6% of Children (under 16) in Sandwell live in low-income households compared to 18.6% nationally and 21.5% regionally.  Single parent households make up 9.0% of Sandwell households, compared to 7.1% nationally and 7.5% regionally. Being in care when young is also a determinant of adult mental health, such as levels of antisocial behaviour, emotional instability and psychosis. 

69.5 out of every 10,000 children in Sandwell are in local authority care, lower than the national average of 60.0/10,000, and lower than the West Midlands average of 74.5/10,000.

Teenage pregnancy is a risk factor for poor mental health outcomes. Teenage mothers are less likely to finish their education, are more likely to bring up their child alone and in poverty and have a higher risk of poor mental health than older mothers.  

In children aged 13-15, the annual rate of conception is 8.2 per 1000 females, higher than the national rate of 4.4 and the regional rate of 5.2. In children aged 15-17, the annual rate of conception is 38.3 per 1000 females, higher than the national rate of 22.8 and the regional rate of 26.5.

 Parental mental illness is a risk factor for childhood mental illness, with children of mothers with mental ill health being five times more likely to have a mental disorder15.  

There are 108.3 parents attending treatment for substance misuse for every 100,000 children in Sandwell. This is on par with the national rate of 110.4. There are 63.2 parents attending treatment for alcohol misuse for every 100,000 children in Sandwell. This is significantly lower than the national rate of 147.2.

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Relationships Having an intimate, trustworthy partner is a protective factor for mental health. Being married appears to be beneficial to mental wellbeing. Married individuals have a greater reported satisfaction with life compared to those who are unmarried. High marital relationship quality is associated with higher wellbeing and lower risk of depression16. 

11.2% of people in Sandwell report their marital status to be separated or divorced. This is slightly lower than the national average of 11.6 and comparable to the regional average of 11.3%.

Lifestyle Several epidemiological studies have shown that physical activity can delay or even prevent the onset of different mental disorders. Exercise also has therapeutic benefits when used as sole or adjunct treatment in mental disorders17. People with psychiatric disorders who exercised regularly reported higher health-related quality of life in a cross-sectional study18. 



Regular exercise and physical activity are associated with improved mental health and wellbeing. Sandwell’s is a relatively inactive population, with only 47.1% engaging in recommended levels of physical activity (compared to 55.5% in the West Midlands, 57.0% in England). It is estimated that only 12.4% of the population use outdoor space for exercise (compared to 17.9% of England, 16.9% of the West Midlands).

Smoking is associated with psychiatric disorders but the causal pathways are unclear. There is some evidence that those who smoke are more likely to develop a mental disorder but further studies are needed to validate this and investigate why19. People with a mental health problem smoke approximately 42% of all cigarettes smoked in England20. Those with severe mental health problems have an average life expectancy of between 10 and 25 years lower than the national average, and it is suspected that smoking is responsible for a large proportion of this excess mortality21,22. Other risk factors include physical inactivity and obesity21.  

20.6 % of people over the age of 18 are current smokers; higher than the national and regional averages of 18.0% and 16.9% respectively. 27.2% of adults in Sandwell are obese – compared to 24.0% nationally and 26.1% regionally.

People with disorders of substance use have higher rates of co-morbid mental disorders than vice versa. The causal pathways differ between both substances and disorders. There is strong evidence in particular that alcohol misuse increases the risk of depression23. 

The percentage of Sandwell residents who drink alcohol at ‘increasing risk’ or ‘higher risk’ levels are estimated to be relatively low at 18.5% (compared to 22.3% nationally and 21.4% regionally). This may be due to differences in ethnic groups.

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The estimated prevalence of opiate and/or crack cocaine use is 10.7/1000 of the population aged 15-64 (higher than the national average of 8.4/1000 and the regional average of 9.5/1000).

Health Mental health and physical health are interlinked, mutually affecting each other. Chronic physical health problems are associated with increased risk of mental health disorders. Depression is 2-3 times more common in people with long-term health conditions13. Equally, poor mental health leads to poor physical health. A person suffering from a mental illness is almost twice as likely to die from coronary heart disease and four times more likely to die from respiratory disease24. An estimated 12-18% of NHS expenditure on the management of long-term conditions is associated with poor mental health and wellbeing25. 

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20.9% of people in Sandwell have a long-term health problem or disability that limits their daily activities. This is higher than the national average of 17.6% and the West Midlands average of 19%. 6.47% of households with dependent children have at least one person with a longterm health problem or disability, higher than the national and regional averages of 4.62% and 5.14% respectively. The health-related quality of life for older people (measured in those over 65 years of age using the EQ-5D scale) is 0.652 in Sandwell (compared to 0.709 in the West Midlands and 0.726 in England).

Social and Economic Factors Deprivation is associated with an increased risk of mental illness. Those in the lowest socioeconomic classes have the highest prevalence of psychiatric disorders26,27. Common mental disorders such as anxiety and depression are distributed along a gradient of economic disadvantage such that the poor and disadvantaged suffer disproportionately from common mental disorders5,28. As an example, the incidence of mental health problems in children from the lowest income families is 12-15%, compared to 5% in children from families with the highest income13. Poorer areas have higher rates of hospital admission for mental illness, and more outpatient mental health service use29. Higher income inequality is linked to higher rates of mental illness, lower social capital, and increased hostility, violence and racism. While poor mental health and well-being can be an outcome of poverty, it can also be a determinant of it, further compounding the problem30. 

 

There are high levels of deprivation in Sandwell. 55.7% of people living in Sandwell are currently living in the 20% most deprived areas in England. (England average 20.2%, the West Midlands average 29.3%). This fact is also reflected in Sandwell’s index of multiple deprivation score (IMD 2015) of 34.6 – significantly higher than the country’s average score of 21.8. [PHOF] 16.4% of the households experience ‘fuel poverty’ – more than the national average of 10.4% and the regional average of 13.9%.

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  

Average (median) gross weekly pay is lower in Sandwell at £453.00 compared to £492.50 in the West Midlands and £532.60 in England10. The Average (median) gross annual pay is £23,241 in Sandwell, £25,650 in the West Midlands, £27,869 in England10. The average gross disposable household income (GDHI) in Sandwell is £12,100, compared to £15,551 in the West Midlands and £17,842 in England.

Employment Having a permanent job is a protective factor for mental health31. Unemployment is associated with poor mental health, increasing both the risk of common mental disorders by a factor of 2.7 and of disabling mental disorders by a factor of 4.3 27.      

67.0% of people of working age (16-64) are in employment (compared to the average of 73.9% in England 70.7% in the West Midlands)10. 8.2% are currently unemployed (compared to England average of 5.1% and the West Midlands average of 5.8%)10. 1.62% of people of working age living in Sandwell are in long-term unemployment (compared to England average of 0.61%, and the West Midlands average of 0.93%). 7% of families in Sandwell have no adults in employment; compared to 4.2% nationally and 4.8% regionally. 3.25% of the local population are providing substantial unpaid care (50+ hours/week) – compared to 2.37% nationally and 2.68% regionally. There is a job density in Sandwell of 0.70 (i.e. there are 7 jobs for every 10 people aged 16-24) – compared to 0.83 in England and 0.78 in the West Midlands10.

Social Cohesion and Capital Social networks and good social support promote wellbeing may be protective against mental health problems12, 32. As stated previously, migrants, refugees and asylum-seekers have a disproportionately higher risk of depression11. 



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Sandwell scores favourably compared to the rest of the country when looking at social isolation. Surveys of users of social care services and of adult carers show that 51.5% and 45.7% respectively have as much social contact as they would like (compared to national averages of 44.8% (44.2% West Midlands) and 38.5% (38.4% West Midlands) respectively). These figures are of limited usefulness however, as they focus on social care users and carers rather than the broader population. The problems of loneliness and social isolation are obviously not limited to these groups. 4.26% of people in Sandwell state they cannot speak English or speak it well. This percentage is dramatically higher than the national average of 1.65% and the regional average of 1.99%. Migrant GP registration provides a proxy measure for the migrant population in a local authority. The Sandwell rate of migrant GP registration is 9.9 per 1000 residents – lower than the national average of 11.7 per 1000 residents.

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Population turnover is lower in Sandwell than the national average (85.3/1000 compared to England’s 90.7/1000), perhaps suggesting a higher degree of social cohesion.

Environmental Factors Violence is negatively associated with mental health and wellbeing. Countries afflicted by violence and war have particularly high rates of mental health problems5. Children exposed to physical and psychological abuse, and those growing up in families with domestic violence are more likely to have psychiatric disorders in adulthood33. 

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Levels of violent crime are relatively low in Sandwell; with 11.4 annual offenses per 1000 population (compared to England average of 13.5/1000, and the West Midlands average of 12.8/1000). The incidence of reported domestic abuse in Sandwell (22.4/1000 population) is higher than the national and regional averages (20.4/1000 & 20.3/1000 respectively).

Housing Being homeless increases the risk of mental disorders. In particular, it multiplies the risk of developing probable psychosis by 11.3 and of neurotic disorder by 3.9. The risk of substance misuse is also associated with homelessness, increasing the risk of alcohol and drug dependence by a factor of 5.5 and 5.6 respectively13.  

4.5 per 1000 people in Sandwell are homeless (compared to England average of 2.4/1000 and the West Midlands average of 3.4/1000). 6.8% of Sandwell households are overcrowded (i.e. having an occupancy rating of -1 or lower); compared to 4.8 nationally and 4.6 regionally.

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Figure 3: Risk and protective factors in Sandwell

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3. Wellbeing, mental health and mental illness in Sandwell The Health Survey for England monitors trends in the nation’s health to estimate the proportion of people in England who have specified health conditions. The most recent survey, published in December 2016, reports the results from a survey undertaken in 201434. This includes a chapter on prevalence of mental illness in the population, including lifetime experience, recent treatment and experience and the relationships between mental illness and the other aspects of people’s lives. Some key findings from this survey were that, in England;  26% of all adults reported having ever been diagnosed with at least one mental illness. A further 18% of adults reported having experienced a mental illness but not having been diagnosed  Women were more likely than men to report ever having been diagnosed with a mental illness (33% compared with 19%).  The most frequently reported mental illness ever diagnosed was depression, including post-natal depression, with 19% of adults (13% of men, 24% of women) reporting this.  The next most frequently reported conditions ever diagnosed were panic attacks, mentioned by 8% of adults, and generalised anxiety disorder, mentioned by 6%. Lifetime prevalence of each other condition was very low, at 3% or less.  People may have more than one condition, and may have conditions and disorders in more than one type (for example, a common mental disorder and a serious mental illness). There is considerable overlap between types. This section will describe the levels of wellbeing and mental health disorders in Sandwell. The data and intelligence presented come from a range of data sources. Some of these report data by local authority boundaries. Other data sources report data for clinical commissioning group boundaries. For each data source the population referred to will be stated. This variation in reporting geographies does make it difficult to draw definitive conclusions about the level of need and of services provision at a Sandwell MBC level. Where possible data will be compared between data sources to provide the most accurate possible picture of the level of need in Sandwell.

Wellbeing in Sandwell The Office of National Statistics (ONS) publishes estimates of well-being for UK local authorities35. These are based four personal wellbeing questions. The questions are based on ten aspects of life that people said mattered to their wellbeing. These include; personal wellbeing, relationships, health, economy and environment. The questions are;  Overall, how satisfied are you with your life nowadays?  Overall, to what extent do you feel the things you do in your life are worthwhile?  Overall, how happy did you feel yesterday?  Overall, how anxious did you feel yesterday?

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People are asked to respond on a scale of 0 to 10, where 0 is “not at all” and 10 is “completely”. Figure 4 shows a comparison between Sandwell, the West Midlands and the England average. This chart shows the percentage of the population who scored low (0-4) for satisfaction, worthwhile and happiness and high (6-10) for anxiety. The differences in low satisfaction and low happiness scores between Sandwell and England are statistically significant. The difference in the number of people reporting a low score for worthwhile and people reporting a high level of anxiety are not statistically significant when compared to the England average. Figure 4: Wellbeing in Sandwell, responses to the ONS 4 wellbeing questions

Percentage of the population

Responses to the Office of National Statistics four wellbeing questions: Sandwell, West Midlands and England 25 20 15 England

10

West Midlands 5

Sandwell

0 Low satisfaction score

Low Low happiness High anxiety worthwhile score score score

ONS question Source: Public Health Profiles In 2014, the Public Health Department undertook a population wellbeing survey in Sandwell. This was a postal survey based on the Short Warwick and Edinburgh Mental Wellbeing Scale (WMWBS). This seven-item questionnaire covers subjective wellbeing and psychological functioning. The profile of the respondents to the survey was biased towards the groups listed below. The findings therefore include consideration of this bias;  The older population aged 65+ (43%)  Those who are retired from work (44%)  Those who suffer from a limiting long term illness (42%) The survey identified that the average wellbeing score for Sandwell as measured by SWEMWBS was 24.37 which was slightly lower than the national average of 25.3 (Health Survey for England 2010, Understanding Society, the UK’s Household longitudinal study 2011).

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More detailed analysis of the SWEMWBS scores has shown that the main factor is likely to be the presence of a long-term illness that significantly limits the individual’s activities. Similarly, those who subjectively assessed their health as bad or very bad had significantly lower wellbeing (20) than those who rated it both fair (22.5) and good or very good (26.5). A limiting long-term illness and subjective assessment of one’s health as bad correlated to the lowest SWEMWBS scores more than all other demographic factors. This finding is supported by the qualitative analysis of the responses to the questions ‘what has the biggest positive and biggest negative effect on your wellbeing’. The responses to this question indicated that participation in hobbies and activities was one of the positive contributing factors and ill health was one of the strong negative contributing factors. Other factors that showed a significant correlation with SWEMWBS wellbeing scores were:  Older age, where those aged 65-74 had a significantly higher level of wellbeing compared to all other age groups. This finding concurs with previous studies on wellbeing that indicate that wellbeing follows a U shaped pattern across the life course36.  Being a carer was positively correlated with higher levels of wellbeing.  Being single or living alone was negatively correlated with wellbeing, which became evident in the qualitative responses where many respondents talked about loneliness having a negative impact on their wellbeing.  In terms of ethnicity, black respondents reported significantly higher wellbeing than all other ethnic groupings.  Non-smokers had higher wellbeing than people who smoke.  Individuals who practice or participate actively in their faith (whether religious or spiritual) have significantly higher wellbeing than those who are non-practicing.  Individuals with higher levels of social trust had significantly higher wellbeing than individuals with low levels of social trust.

Common mental health conditions: Estimates of prevalence for common mental health disorders vary considerably. NICE guidance provides estimates for prevalence based on the Office of National Statistics 2007 national survey37.  Generalised anxiety disorder – 4.4%  PTSD – 3.0%  Depression – 2.3%  Phobias – 1.4%  Obsessive-compulsive disorder – 1.1%  Panic disorder – 1.1% Estimates of proportion of people who are likely to experience specific disorders during their lifetime are;  Major depression – 4%-10%  Generalised anxiety disorder – 5.7% Item 6a Draft Adult MHW Jsnaa 04/01/2017 39

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Panic disorder – 1.4% Specific phobias – 12.5% Social anxiety disorder – 1.6% Obsessive compulsive disorder – 1.6% Post-traumatic stress disorder – 6.8%

There are limitations to the data available to describe the levels of common mental health disorders in Sandwell. Much of the data comes from GP practice data, for which there are difficulties with recording and variations between practices in data completion and quality. This approach will not identify people not in contact with primary care. Other data comes from hospital admissions, and there are variations in the recording of admissions and hospital contacts between areas and providers. Where data is limited or contradictory, it is important to examine different sources of intelligence to support triangulation of intelligence. This can provide the most complete picture possible given the available data. The following section will examine a number of different data sources. Public Health England publishes annual local area profiles that summarise the data and intelligence about common mental health disorders based on clinical commissioning group boundaries38. Table 1 provides a summary of these indicators based on the geographical footprint of Sandwell and West Birmingham clinical commissioning group (SWCCG). Table 1: Common mental health conditions: summary indicators Indicator

Time period People estimated to have any common 2014/15 mental health disorder. Estimated % of population aged 16-74 Recorded prevalence of depression 2014/15 aged 18+ New cases of depression: Adults with a 2014/15 new diagnosis of depression as a % of all patients on the GP register Depression and anxiety among GP 2013/14 survey respondents: % of people completing GP patient survey reporting they feely moderately or extremely anxious or depressed Secondary care contacts for common 2014/15 mental health disorders: Rate per 100,000 population aged 18+ Use of mental health services by BME 2012/13 groups Percentage of mental health service users Source: Public Health Outcomes Framework Item 6a Draft Adult MHW Jsnaa 04/01/2017 40

SWBCCG

England

16.10

10.29

Statistical significance Not measured

6.16

7.33

Sandwell lower

0.98

1.20

No difference

14.1

7.2

Sandwell higher

803

532

Sandwell higher

36.78

11.19

Sandwell higher

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The last of these indicators, use of services by people from BME groups, identifies that the proportion of BME groups in the Sandwell population is 30.06%, the data shows that they make up 36.78% of people using services. However, there are uncertainties and possible inconsistencies in how ethnicity is recorded. At this time, it is not possible to determine whether this difference between population and service use is statistically significant. Sandwell and West Birmingham Clinical Commissioning Group commission the Black Country Partnership Foundation Trust (BCPFT) to provide mental health services for the population of Sandwell. Data from BCPFT on referrals into their services is shown below in figures 5 and 6. Figure 5 shows the proportion of referrals by ethnicity for each of the previous five years. This shows a possible increase in referrals from black and Asian groups, although it is not possible to identify whether this trend is significant. Figure 5: Referrals by ethnicity 2011/12 to 2015/16

Proportion of referrals (%)

Referrals by ethnicity 2011/12 to 2015/16 80.0 70.0 60.0 White

50.0

Asian

40.0

Black

30.0

Any Other Group

20.0

Mixed groups

10.0

Not known

0.0 2011/12 2012/13 2013/14 2014/15 2015/16

Year Figure 6 shows the proportion of referrals from each ethnic group compared to the proportion of that group within the population. This shows a possible under representation of Asian groups in referrals into services compared to the proportion of Asian groups in the population. Recent studies have shown that, in general, people from Black backgrounds are overrepresented in mental health services, especially in acute services and in people subject to detention under the Mental Health Act39. From the data from BCPFT, this over representation is not apparent in referrals into services in Sandwell. Further data collection and analysis will be required to understand the ethnicity of people in acute mental health services or in detention under the Mental Health Act in Sandwell.

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Figure 6: Referrals by ethnicity: Ethnicity compared to population proportion: total referrals 2011 to 2015

Proportion (%)

Total referrals 2011 to 2016 by ethnicity compared to population 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Referrals Population White

Asian

Black

Any Mixed Not Other groups known Group

Ethnic group

Much of the data on common mental health disorders comes from general practice registers. This introduces possible bias into the data. Not all people register with GPs, and people who are particularly vulnerable may be less likely to register with a GP. For example, people who are homeless, people misusing alcohol or drugs and new arrivals. There are also concerns regarding the variation in the quality and completeness of data recording between primary care practices. There are inconsistencies between the data sources. For example, the levels of common mental health problems identified through GP practice surveys are higher than the levels of these problems registered on practice registers. Other intelligence comes from hospital contacts for people with mental health disorders. Although the rates of diagnosis for common mental health disorders on GP registers are lower than England, the number of secondary care contacts for common mental health disorders are higher than England. Table 2: Hospital contacts for common mental health disorders Indicator Emergency admissions for depression per 100,000 population Emergency admissions for neuroses per 100,000 population A&E attendances for a psychiatric disorder People coming into contact with CCG mental health services per 100,000 population

Time period 2014/15

SWBCCG

England

36

32.1

Statistical significance Similar

2014/15

27.1

21.7

Similar

2014/15

54.4

243.5

2013

2732

2160

Sandwell lower Sandwell higher

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Source: Public Health Outcomes Framework Prescribing levels for medications used for common mental health disorders also provide information on the level of identified need in Sandwell. This will only identify people who have been diagnosed with a mental health disorder, so will be subject to the same limitations as other GP practice based data. To compare one GP practice or clinical commissioning group to another, the size of the practice or CCG has to be taken into account. Practices with more patients on their lists will need to prescribe more. Prescribing rate can be expressed as the number of prescriptions per patient (or per number of patients) on the practice list. However, comparative data can be analysed using a variety of patient denominators such as STAR-PU; ‘specific therapeutic group age-sex related prescribing units’ that allow for benchmarking of spend between areas. Table 3 shows the prescribing levels for common mental health disorders in Sandwell compared to the England average.

Table 3: Prescribing levels of medications for common mental health disorders Indicator Primary care prescribing spend on mental health (£) per person Antidepressant prescribing: average daily qualities (ADQs) per STAR-PU Hypnotics prescribing: average daily qualities (ADQs) per STAR-PU Source: Public Health Outcomes Framework

Time period 2013/14

SWBCCG

England

11.47

12.31

2015/16

1.09

1.36

2015/16

0.90

0.99

These show that the levels of prescribing of antidepressants and hypnotics are lower in Sandwell than the England average. The statistical significance of these differences between Sandwell and England is not benchmarked within the data source. These data as presented provide an indication of the prevalence of common mental health disorders within the population. However, due to the limitations of the data, as discussed, they cannot provide a complete and definitive picture of the level of need in Sandwell.

Referrals into services Referrals into mental health services provide information on the numbers of people accessing mental health services in Sandwell. The data presented in this section does not identify the reasons for referral or separate common mental health disorders from severe and enduring mental illness, but it does provide information to support triangulation across data sources.

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Sandwell and West Birmingham Clinical Commissioning Group commission the Black Country Foundation Partnership Trust (BCPFT) to provide mental health services for the population of Sandwell. Figure 7 shows the pattern of referrals by age of the person referred. This shows an increase in the number of referrals at age 9, reflecting the age criteria for the services provided. The number of referrals then decreases between 40 and 60. After this, the number of referrals increases to a peak at around age 80 years. It is likely that this is due to increased referrals for age related mental illness including dementia. Figure 7: Referrals by age: Total referrals 2011 to 2016 Referrals by age 2011 to 2016

Number of referrals

2,500

2,000

1,500

1,000

500

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105

0

Age Figure 8 shows the pattern of referrals by gender over the past five years. Over 2011 to 2013 the data show a higher rate of referrals for females, whereas in 2015/16 there is a possible higher rate of referral for males. At this point the data does not allow for a clear conclusion about whether these are significant differences or normal variation.

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Figure 8: Referrals by gender 2011/12 to 2015/16 Referrals by gender 2011/12 to 2015/16 14,000

Number of referrals

12,000 10,000

8,000 Female

6,000

Male 4,000 2,000 0 2011/12

2012/13

2013/14

2014/15

2015/16

Year

Figure 9 shows the routes of referrals into mental health services. This is relevant to this needs assessment because of the focus on access into services. However, with the substantially increased proportion from the non-defined ‘other’ category it is not possible to be clear on whether the pattern of referrals has changed over this period. Figure 9: Referrals by source of referral Referrals by source 2011/12 to 2015/16

A&E DEPARTMENT ALLIED HEALTH PROFESSIONAL

14,000

CONSULTANT

Number of referrals

12,000

CONSULTANT WITHIN TRUST FOLLOWING A CONSULTANT DOMICILIARY VISIT FOLLOWING A LIAISON PSYCHIATRY ATTENDANCE FOLLOWING AN EMERGENCY ADMISSION GENERAL PRACTITIONER

10,000 8,000 6,000

GP

4,000

OTHER OTHER CONSULTANT NOT A&E

2,000

OTHER INITIATED BY CONSULTANT IN CHARGE OTHER SOURCE

0 2011/12 2012/13 2013/14 2014/15 2015/16

Year

SELF-REFERRAL SPECIALIST NURSE (SECONDARY CARE)

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Suicide and self-harm Data on self-harm is available from the public health outcomes framework. The data available are hospital stays due to self-harm in Sandwell (figure 10). The difference in the rates between England and Sandwell are statistically significant, with Sandwell having consistently higher rates of hospital admission due to self-harm. Figure 10: hospital stays for self-harm, Sandwell and England: 2012/13 to 2014/15 260

Rate per 100,000 population

240 220 200 180

Sandwell West Midlands

160

England 140 120 100

2012/13

2013/14 Year

2014/15

The Office of National Statistics collates data on suicide at a local authority level. This includes both deaths due to suicide and those due to injury of undetermined intent. Figure 11 shows the level of suicide in Sandwell compared to the West Midlands region and England. The trend is for the suicide rate in Sandwell to be slightly lower than that for West Midlands and for England, though this difference is not statistically significant. The Parliamentary Health Select Committee has recently published a report from a review of suicide and suicide prevention in England. This has found that there is significant variation in the recording of suicide between areas, largely due to the differences in how coroners record deaths40. This means that the variation in suicide rates between areas may not reflect the actual number of suicides. The report has recommended that coroners are supported to improve consistency in how suicide is recorded.

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Figure 11: Age-standardised mortality rate from suicide and injury of undetermined intent per 100,000 population: Sandwell, West Midlands and England

Severe and enduring mental illness Table 4 shows summary indicators from the public health outcomes framework for severe and enduring mental illness in Sandwell and West Birmingham CCG, compared to England. Table 4: Severe and enduring mental illness: summary indicators Indicator

Time Period 2012

SWBCCG

England

0.51

0.40

Statistical significance Not measured

2014/15

1.05

0.88

Sandwell higher

2012/13

78.20

58.60

Sandwell higher

GP prescribing of drugs for psychoses 2015/16 and related disorders: items (quarterly) per 1000 population Schizophrenia emergency admissions: 2009/10 rate per 100,000 population aged 18+ – 11/12 Source: public health outcomes framework

45.04

46.87

Sandwell lower

58.00

57.0

Similar

Estimated prevalence of psychotic disorder – percentage of population aged 16+ QOF prevalence of severe mental illness: percentage of people on GP register Detentions under the Mental Health Act, annual rate per 100,000 population

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This data indicates that Sandwell may have a higher rate of severe mental illness, including psychotic illness, than the England average. Recent studies have shown that some ethnic groups, specifically Black, are often overrepresented in severe mental illness services and in detentions under the Mental Health Act. More work will be needed to understand the ethnicity of people in these services to determine whether this is the case in Sandwell.

Perinatal Mental Health It is estimated that between 10% and 20% of women are affected by mental health problems at some point during pregnancy or in the first year after childbirth 41. Perinatal mental health is a priority in Sandwell, particularly in relation to children’s and young people’s mental health and wellbeing. It is a priority within the Sandwell Child and Adolescent Mental Health Services (CAMHS) Transformation Plan42. The National Child and Maternal Health Intelligence Network provides estimates of the prevalence of perinatal mental health disorders in Sandwell. These estimates are calculated by applying the national prevalence to the population of Sandwell. Due to the limitations associated with the estimates it is not possible to benchmark against other areas43. This data is summarised in table 5. Table 5: Estimates of women with mental health problems during pregnancy and after childbirth Indicator

Time period

Estimated number of women with postpartum psychosis Estimated number of women with chronic serious mental illness Estimated number of women with severe depressive illness Estimated number of women with mild-moderate depressive illness and anxiety (lower estimate) Estimated number of women with mild-moderate depressive illness and anxiety (upper estimate) Estimated number of women with post-traumatic stress disorder Estimated number of women with adjustment disorders and distress (lower estimate) Estimated number of women with adjustment disorders and distress (upper estimate)

2013/14 2013/14

Sandwell (number) 10 10

2013/14 2013/14

135 450

2013/14

675

2013/14

135

2013/14

675

2013/14

1,345

Co-existing mental illness and substance misuse Dual diagnosis refers to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders, bipolar affective disorder and severe depressive episodes with or without psychotic episodes) combined with misuse of substances (the use Item 6a Draft Adult MHW Jsnaa 04/01/2017 48

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of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage). Recent studies have estimated prevalence rates of 20-37% in secondary mental health services and 6-15% in substance misuse settings44. Difficulties in accessing services for this group have been reported both nationally and locally44. During the stakeholder consultation for this needs assessment there was anecdotal reporting of people with a substance misuse problem having difficulty accessing both mental health and wider physical health services. People who misuse alcohol over a long period are at risk of alcohol related brain damage (ARBD). This can lead to difficulty with memory and possible confusion. This can make it more difficult for people with ARBD to access services and to maintain treatment. They are likely to need more intensive support to manage their alcohol intake 45. Table 6 shows the summary indicators for co-existing mental illness and substance misuse in Sandwell compared to England. Table 6: Co-existing mental illness and substance misuse: summary indicators Indicator

Time period 2011/12

Estimated prevalence of opiate and/or crack cocaine use per 1000 population aged 15-64 Admission to hospital for mental and 2014/15 behavioural disorders due to alcohol per 100,000 population Concurrent contact with mental health 2014/15 services and substance misuse services for alcohol misuse (proportion of all individuals entering alcohol services) Concurrent contact with mental health 2014/15 services and substance misuse services for drug misuse (proportion of all individuals entering drug services) Source: Public Health Outcomes Framework

Sandwell England 10.73

8.40

Statistical significance Sandwell higher

105.69

84.39

Sandwell higher

25.28

20.01

Similar

17.46

20.96

Similar

These indicators suggest that overall drug use is higher in Sandwell than in England, and admissions to hospital for alcohol related behavioural disorders are higher than the England average. Concurrent contact with mental health services and substance misuse services are similar to the England average. Local service data provides more detail for Sandwell. Of 901 individuals commencing a new treatment journey in 2015/16, 149 (16.5%) were recorded as having a dual diagnosis need.

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Analysis by substance type shows: Alcohol only: Opiates: Non-opiates: Non-opiates and alcohol:

15.5% 14.9% 21.5% 24.7%

Those individuals with a dual diagnosis need receive additional support from a community psychiatric nurse within the service but this does not negate the need for clients to be able to access mainstream mental health services.

Health of people with mental illness People with severe mental illness have a 10 to 25 year shorter life expectancy than the general population. The majority of these deaths are due to long-term health conditions such as cardiovascular disease, respiratory and infectious diseases, diabetes and hypertension. The other major cause of death is suicide.46 This higher prevalence of long-term conditions in this population is largely caused by unhealthy lifestyles such as smoking, physical inactivity and diet. People with severe mental illness are often at a socioeconomic disadvantage, are far less likely to be employed and to suffer substantial discrimination. Table 7 summarises the main available indicators for the health of people with severe mental illness in Sandwell. Table 7: Health of people with severe mental illness in Sandwell: summary indicators Indicator

Time period 2012/13

Premature (